Temporal trends in COVID-19 outcomes in people with rheumatic diseases in Ireland: data from the COVID-19 Global Rheumatology Alliance registry.

OBJECTIVES: Although evidence is accumulating globally, data on outcomes in rheumatic disease and COVID-19 in Ireland are limited. We used data from the COVID-19 Global Rheumatology Alliance (C19-GRA) to describe time-varying COVID-19 outcomes for people with rheumatic disease in Ireland. METHODS: Data entered into the C19-GRA provider registry from Ireland between 24 March 2020 and 9 July 2021 were analysed. Differences in the likelihood of hospitalization and mortality according to demographic and clinical variables were investigated using Chi-squared test or Fisher's exact test, as appropriate. Trends in odds of hospitalization and mortality over time were investigated using logistic regression with the time period as a categorical variable. RESULTS: Of 212 cases included, 59.4% were female and median age was 58.0 years (range 13-96). Of the 212 cases, 92 (43%) were hospitalized and 22 (10.4%) died. Increasing age, a diagnosis of gout, ever smoking, glucocorticoid use, having comorbidities and specific comorbidities of cancer, cardiovascular and pulmonary disease were more common in those hospitalized. A diagnosis of inflammatory arthritis, csDMARD and/or b/tsDMARD use were less frequent in those hospitalized. Increasing age, a diagnosis of gout, ever smoking, having comorbidities and specific comorbidities of obesity, cardiovascular and pulmonary disease were more common in those who died. Odds of hospitalization or mortality did not change over time. CONCLUSION: No temporal trend was observed in either COVID-19-related hospitalization or mortality outcomes for people with rheumatic disease in Ireland.

Disinfection of the Radiologist Workstation and Radiologist Hand Hygiene: A Single Institution Practice Quality Improvement Project.

PURPOSE: The purpose of this study was to evaluate the workstation disinfection rates and hand hygiene of radiologists and trainees at shared departmental workstations and assess the impact of education and reminder placards on daily habits. METHODS: A 10-question survey was administered to all staff radiologists, fellows, and residents at our institution. The questions pertained to workstation disinfection, hand hygiene habits, and accessibility to disinfectant wipes and hand sanitizer stations. Subsequently, a short educational PowerPoint presentation was emailed to the department and small reminder placards were placed at each workstation. A follow-up survey was administered. Chi-square and Wilcoxon signed-rank tests were used to analyse the results. RESULTS: The percentage of participants who disinfect their workstations 1-2 times/week, 3-4 times/week or everyday increased from 53.4% (45 of 84 participants) to 74.3% (55 of 74 participants; P = .01), while the number who disinfect their workstation <1 time/week or never decreased from 46.4% (39 of 84 participants) to 25.7% (19 of 74 participants; P = .01). Hand washing before working at the workstation increased from 41.6% (35 of 84 participants) to 48.7% (36 of 74 participants; P = .76) and hand washing after working at the workstation increased from 50.0% (42 of 84 participants) to 56.8% (42 of 74 participants; P = .49). CONCLUSIONS: At our institution, the implementation of daily reminder placards at each workstation and the administration of an educational PowerPoint presentation improved the rate of radiologist workstation disinfection.

A targeted educational intervention increases oral anticoagulation rates in high-risk atrial fibrillation patients.

Background: Anticoagulation is the cornerstone of atrial fibrillation (AF) management for stroke prevention. Recently, we showed that oral anticoagulation (OAC) rates of AF patients in a large U.S. multispecialty health system are >80%. Objective: The purpose of this study was to improve OAC rates in AF patients via an educational intervention targeted to primary care providers with low OAC rates. Methods: Primary care clinicians were stratified by proportions of their AF patients at elevated stroke risk not taking anticoagulation medication. Clinicians with the lowest rates of anticoagulation were assigned to a target group receiving an educational program consisting of E-mail messaging summarizing anticoagulation guidelines. All other clinicians were assigned to a comparison group (CG). Data from a 6-month lead-in phase were compared with a 6-month follow-up period to determine whether the proportion of AF patients treated with OACs had changed. Results: Of the 141 primary care clinicians with patients who met the inclusion criteria, 36 (25.53%) were assigned to the educational group (EG) and 105 (74.47%) to the CG. At baseline, there was a significant difference in percent of high-risk AF patients who were untreated in the EG (20.65%) compared to the high-risk patients who were untreated in the CG (13.64%; P = .001). After the educational intervention, high-risk AF patients without anticoagulation decreased in both EG (15.47%; P = .047) and CG (10.14%; P = .07), with greater absolute reduction in the EG (5.19% vs 3.50%). Conclusion: A targeted education program was associated with increased anticoagulation rates for AF patients at high risk for stroke.

Microarray-based gene expression profiling in patients with cryopyrin-associated periodic syndromes defines a disease-related signature and IL-1-responsive transcripts.

OBJECTIVE: To analyse gene expression patterns and to define a specific gene expression signature in patients with the severe end of the spectrum of cryopyrin-associated periodic syndromes (CAPS). The molecular consequences of interleukin 1 inhibition were examined by comparing gene expression patterns in 16 CAPS patients before and after treatment with anakinra. METHODS: We collected peripheral blood mononuclear cells from 22 CAPS patients with active disease and from 14 healthy children. Transcripts that passed stringent filtering criteria (p values≤false discovery rate 1%) were considered as differentially expressed genes (DEG). A set of DEG was validated by quantitative reverse transcription PCR and functional studies with primary cells from CAPS patients and healthy controls. We used 17 CAPS and 66 non-CAPS patient samples to create a set of gene expression models that differentiates CAPS patients from controls and from patients with other autoinflammatory conditions. RESULTS: Many DEG include transcripts related to the regulation of innate and adaptive immune responses, oxidative stress, cell death, cell adhesion and motility. A set of gene expression-based models comprising the CAPS-specific gene expression signature correctly classified all 17 samples from an independent dataset. This classifier also correctly identified 15 of 16 post-anakinra CAPS samples despite the fact that these CAPS patients were in clinical remission. CONCLUSIONS: We identified a gene expression signature that clearly distinguished CAPS patients from controls. A number of DEG were in common with other systemic inflammatory diseases such as systemic onset juvenile idiopathic arthritis. The CAPS-specific gene expression classifiers also suggest incomplete suppression of inflammation at low doses of anakinra.

Current concepts in the imaging of uterine sarcoma.

Recent advances in genetics and pathology have improved our understanding of diagnosis and staging of uterine sarcomas. The major types of uterine sarcomas include leiomyosarcoma, low-grade endometrial stromal sarcoma, undifferentiated endometrial sarcoma, adenosarcoma and carcinosarcoma. The distinctive biological behavior and poor overall survival of uterine sarcoma create challenges in the management of these tumors. We herein present a comprehensive review of taxonomy, epidemiology, pathology, imaging findings and natural history of a wide spectrum of uterine sarcomas.

Outcomes of COVID-19 in people with rheumatic and musculoskeletal disease in Ireland over the first 2 years of the pandemic.

BACKGROUND: Poor COVID-19 outcomes occur with higher frequency in people with rheumatic and musculoskeletal diseases (RMD). Better understanding of the factors involved is crucial to informing patients and clinicians regarding risk mitigation. AIM: To describe COVID-19 outcomes for people with RMD in Ireland over the first 2 years of the pandemic. METHODS: Data entered into the C19-GRA provider registry from Ireland between 24th March 2020 and 31st March 2022 were analysed. Differences in the likelihood of hospitalisation and mortality according to demographic and clinical variables were investigated. RESULTS: Of 237 cases included, 59.9% were female, 95 (41.3%) were hospitalised, and 22 (9.3%) died. Hospitalisation was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular and pulmonary disease, and cancer. Hospitalisation was less frequent in people with inflammatory arthritis and conventional synthetic or biologic disease-modifying antirheumatic drug use. Hospitalisation had a U-shaped relationship with disease activity, being more common in both high disease activity and remission. Mortality was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular disease, pulmonary disease, and obesity. Inflammatory arthritis was less frequent in those who died. CONCLUSION: Hospitalisation or death were more frequently experienced by RMD patients with increasing age, certain comorbidities including potentially modifiable ones, and certain medications and diagnoses amongst other factors. These are important 'indicators' that can help risk-stratify and inform the management of RMD patients.

Predictors of hospitalization in patients with rheumatic disease and COVID-19 in Ireland: data from the COVID-19 global rheumatology alliance registry.

OBJECTIVES: Given the limited data regarding the risk of hospitalization in patients with rheumatic disease and coronavirus disease 2019 (COVID-19) in Ireland, we used the COVID-19 Global Rheumatology Alliance (GRA) registry data to study outcomes and their predictors. The primary objective was to explore potential predictors of hospitalization. METHODS: We examined data on patients and their disease-related characteristics entered in the COVID-19 GRA provider registry from Ireland (from 24 March 2020 to 31 August 2020). Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with hospitalization. RESULTS: Of 105 patients, 47 (45.6%) were hospitalized and 10 (9.5%) died. Multivariable logistic regression analysis showed that age [odds ratio (OR) = 1.06, 95% CI 1.01, 1.10], number of co-morbidities (OR = 1.93, 95% CI 1.11, 3.35) and glucocorticoid use (OR = 15.01, 95% CI 1.77, 127.16) were significantly associated with hospitalization. A diagnosis of inflammatory arthritis was associated with lower odds of hospitalization (OR = 0.09, 95% CI 0.02, 0.32). CONCLUSION: Increasing age, co-morbidity burden and glucocorticoid use were associated with hospitalization, whereas a diagnosis of inflammatory arthritis was associated with lower odds of hospitalization.

Facilitating patient self-management through telephony and web technologies in seasonal influenza.

PURPOSE: The aim of this project was to develop and test information technology implementations that could assist patients with influenza self-management in primary care settings. Although testing was conducted in the context of seasonal influenza, the project aimed to develop a blueprint that primary care practices could use in an influenza pandemic. METHODS: Four primary care practice-based research networks (PBRNs) systematically designed, implemented, tailored and tested a tiered patient self-management technology model in 12 primary care practices during the peak of the 2007 to 2008 influenza season. Participating clinicians received a customised practice website that included a bilingual influenza self-triage module, a downloadable influenza toolkit and electronic messaging capability. As an alternative option, a bilingual, interactive seasonal influenza telephone hotline that patients could call for assistance was provided. RESULTS: Influenza self-management web pages presented via nine customised practice websites received 1060 hits between February and April of 2008. The Self-management Influenza Toolkit was downloaded 76 times and 185 Influenza Self-Triage Module sessions were completed via practice websites during the course of testing. Logs of the telephony hotline indicated 88 calls between February and April 2008. Seventy-two percent of callers had influenza-like symptoms and 18% were eligible for antiviral therapy. The Spanish language option was selected by 21% of callers. Qualitative feedback from 37 patients (29 English and 8 Spanish) and six clinicians from four PBRNs indicated ease of use, problem-free access and navigation, useful and adequate information that was utilised in various ways by patients and a high level of overall satisfaction with these technologies. Both patients and clinicians provided rich and meaningful feedback about future improvements. CONCLUSIONS: Primary care patients and their clinicians can adopt and successfully utilise influenza self-management technologies. Our pilot study suggests that web resources combined with telephony technology are feasible to set up and easy to use in primary care settings.

Cost and policy implications from the increasing prevalence of obesity and diabetes mellitus.

BACKGROUND: The increasing prevalence of obesity and type 2 diabetes mellitus (DM), among children and adults, has posed important policy and budgetary considerations to government, health insurance companies, employers, physicians, and health care delivery systems. OBJECTIVE: This article examines issues that are common to obesity and DM, including cost, clinical research, and treatment barriers, and proposes health policies to address these issues. METHOD: A manual review was performed of authoritative literature from peer-reviewed medical publications and recently published medical textbooks. RESULTS: Obesity has been disproportionately prevalent among women and minorities, accompanied by an increased risk for DM. Women have experienced an increased risk for the metabolic syndrome, DM, and cardiovascular disease after onset of menopause. Obesity has been related to an increased risk for breast cancer among women, and may be a barrier that prevents women from being screened for colon and breast cancers. Maternal obesity has been a risk factor for gestational DM. CONCLUSIONS: Obesity and DM represent crises for the health care system and the health of the public, incurring costs and disease burden for adults and children, with increasing costs and prevalence expected unless more coordinated efforts to address the causes of these conditions at the national level are implemented. An investment in infrastructure to promote increased physical activity and reward weight management may be budget neutral in the long term by reducing the costs of morbidity and mortality. About two thirds of the costs from DM complications could be averted with appropriate primary care.

Palmar fasciitis and polyarthritis syndrome associated with non-small-cell lung carcinoma.

A 56-year-old man presented with pain and stiffness in both shoulders and developed severe, rapidly progressive contractures of the fingers. Examination revealed subcutaneous thickening in both palms with fixed flexion deformities of all digits except the thumbs. Initial investigations including a malignancy screen were all normal/negative. Eighteen months later, he was diagnosed with metastatic non-small-cell lung carcinoma. Although rare, palmar fasciitis and polyarthritis syndrome is an important paraneoplastic syndrome for rheumatologists to be aware of, as the musculoskeletal symptoms may precede neoplastic manifestations by many months and may improve with appropriate treatment.

Investigating Idiopathic Inflammatory Myopathy; Initial Cross Speciality Experience with Use of the Extended Myositis Antibody Panel.

The discovery of unique autoantibodies has informed and altered our approach to the diagnosis and management of the inflammatory myopathies. This study reports the initial clinical experience of use of the Extended Myositis Antibody (EMA) panel in the largest university teaching hospital in Ireland. We conducted a retrospective review of all patients who had serum samples tested for myositis specific antibodies and myositis associated antibodies from April 2014 to March 2015. A positive EMA panel was of significant clinical utility in facilitating decisions on appropriate investigations, and need for onward referral to other physicians. Furthermore, this paper highlights the diversity of possible presentations of idiopathic inflammatory myopathy with subsequent need for multi-speciality involvement, and serves to heighten awareness among clinicians of the diagnostic use of extended myositis antibody testing in these cases.

Clinical outcomes and incremental costs from a medication adherence pilot intervention targeting low-income patients with diabetes at risk of cost-related medication nonadherence.

PURPOSE: The extent to which reducing cost-related barriers affects diabetes outcomes and medication adherence among uninsured patients is not known. The purpose of these analyses was to understand the clinical impact and cost considerations of a prescription assistance program targeting low-income, minority patients with diabetes and at high risk for cost-related medication nonadherence. METHODS: Patients received diabetes medications without copayments for 12 months. Change in diabetes control was calculated by using glycosylated hemoglobin (HbA1c) level at follow-up compared with baseline. Clinical data were collected from the electronic health record. Medication adherence for diabetes medications was estimated by using proportion of days covered (PDC). Incremental acquisition and per-patient costs, based on actual hospital medication costs, were calculated for different baseline HbA1c levels. FINDINGS: Patients with baseline HbA1c levels ≥7%, ≥8%, and ≥9% experienced mean HbA1c reductions of 0.82% (P = 0.008), 1.02% (P = 0.010), and 1.47% (P = 0.010), respectively, during the 12-month period. The average PDC was 70.55%; 45.24% had a PDC ≥80%, indicating an adequate level of medication adherence. Medication adherence ≥80% was associated with ethnicity (P = 0.015), whereas mean PDC was associated with number of diabetes medication classes used (P = 0.031). Acquisition cost for 1242 prescriptions filled by 103 patients was $13,365.82, representing per-patient costs of $132.39; however, as baseline targets increased, acquisition costs decreased and per-patient costs increased from $10,682.59 and $169.56 to $6509.91 and $192.27, respectively. IMPLICATIONS: Clinically significant reductions in HbA1c levels were achieved for all patients, although greater reductions were achieved with modest per-patient cost increases when considering patients with uncontrolled diabetes. Incorporating a multifactorial intervention to address cost-related medication nonadherence with a behavior change component may yield greater reductions in HbA1c with improved diabetes outcomes and meaningful hospital-based cost savings.

Participation in and impact of a depression care management program targeting low-income minority patients in an urban community-based clinic.

BACKGROUND: African American people experience disproportionately higher rates of chronic depression, and among those affected, the condition is less likely to be detected and treated than in non-Hispanic white people. OBJECTIVE: To address this disparity in our primary care clinic, we introduced a validated framework for detecting and managing depression. METHODS: Over a 5-year period, there were 146 patients diagnosed as having depression and enrolled in a depression care management program. We evaluated the feasibility and effectiveness of that program using baseline and follow-up screening data from the Patient Health Questionnaire-9. RESULTS: The mean baseline severity score of 20.60 was reduced to 15.89 at 6 months (P < 0.001) and to 16.62 at 12 months. Patients achieved their best score, a mean of 12.93, 10.14 months after baseline (P < 0.001). The last mean severity score, after 15.47 months, was 14.60, a significant difference compared with baseline (P < 0.001). Although baseline severity scores for both groups were similar (P = 0.534), patients who remained engaged with the program demonstrated better scores and achieved greater severity score reductions from baseline to the last measure (P < 0.001). This study did not find any differences between the sexes when comparing PHQ-9 scores at baseline (P = 0.074), 6 months (P = 0.303), and 12 months (P = 0.429) and best (P = 0.875) and last (P = 0.640) scores. CONCLUSIONS: Most of the improvement was witnessed in the first 10 months of treatment. Patients with more medical comorbidities participated longer in the study than patients with fewer comorbidities. Further research could elicit the relationship between improvement in mental health and medical conditions.

Short and long-term outcomes from a multisession diabetes education program targeting low-income minority patients: a six-month follow up.

BACKGROUND: A diabetes self-management education (DSME) program was offered to patients at a primary care clinic serving low-income people. OBJECTIVES: The purpose of the analyses presented here was to understand the feasibility of the program and effectiveness of the intervention. METHODS: The program was facilitated by a nurse and licensed dietician. Data were collected at baseline, after each class, and after 6 months. Patients were interviewed to identify diabetes self-care behaviors before the first class, after the fourth class, and at 6 months. Knowledge related to content areas was measured before and after each class. Glycosylated hemoglobin (HbA(1c)), blood pressure, weight, and body mass index (BMI) were collected at baseline and after 6 months. Medical records were reviewed for LDL levels, co-morbidity, and diabetes management. Frequencies, χ(2) and t tests, and repeated measures t tests were used to analyze data. RESULTS: Patients were mostly non-Hispanic black or Hispanic (93.1%); mean BMI was 34.89 kg/m(2). About one-half (41.95%) completed the program. Significant improvements were observed for knowledge related to each of the 4 content areas: diet (P < 0.001), diabetes management (P = 0.003), monitoring blood glucose (P < 0.001), and preventing complications (P = 0.001). Among long-term outcomes, mean HbA(1c) was significantly reduced (0.82%), from 8.60% to 7.78% (P = 0.007), with 26.67% of patients reducing HbA(1c) from ≥7.0% at baseline to <7% at follow up (P < 0.001). Patients demonstrated a significant improvement in readiness to improve dietary behaviors (P = 0.016). CONCLUSIONS: Outcomes suggested that minority patients with a high risk for poor diabetes outcomes might be retained in a multisession DSME program and benefit from increasing knowledge of diabetes content. Further evaluation is necessary to determine the cost-effectiveness of this intervention.

Feasibility of an internet-based intervention for improving diabetes outcomes among low-income patients with a high risk for poor diabetes outcomes followed in a community clinic.

PURPOSE: The purpose of this study was to determine the feasibility of an Internet-based intervention, targeting very low-income minority patients with a high risk for not engaging in diabetes self-management, to increase diabetes self-management and improve diabetes outcomes. METHODS: Patients with diabetes followed in a community clinic were enrolled in the 13-month trial. Participants were requested to test blood sugar and upload glucometer data every day and login to the program at least once every second day. Feasibility data included process measures; diabetes outcomes consisted of changes from baseline to follow-up for levels of glycosylated hemoglobin (A1C), LDL, HDL, triglyceride and total cholesterol, and health-related quality of life using the SF-36. RESULTS: Only 22% of participants had health insurance. Participants had an average of 4.39 comorbidities and 7.06 prescriptions. Participants uploaded glucometer data at least twice each week and logged into the application at least once each week. Participants demonstrated reductions statistically or clinically important changes in A1C, LDL cholesterol, total cholesterol, and triglyceride levels. Participants engaging in more frequent chat messages and interactive activities demonstrated greater reductions in LDL cholesterol levels; however, engaging in more frequent chat messages also was associated with increased triglyceride levels. Participants rated fewer role limitations from physical health problems at follow-up. CONCLUSIONS: The intervention produced good outcomes; however, an alternative platform may be a less expensive approach.

MDCT of abdominopelvic oncologic emergencies.

Acute complications arising in abdominopelvic malignancies represent a unique subset of patients presenting to the emergency room. The acute presentation can be due to complications occurring in the tumor itself or visceral or vascular structures harboring the tumor. Multidetector computed tomography (MDCT) is the investigation of choice in the workup of these patients and enables appropriate and timely management. Management of the complication depends primarily on the extent of the underlying malignancy and the involvement of other viscera. The purpose of this article is to depict the imaging features of these complications on MDCT.

Mucinous neoplasms of the appendix: a current comprehensive clinicopathologic and imaging review.

Mucinous neoplasms of the appendix are a heterogeneous group of neoplasms ranging from simple mucoceles to complex pseudomyxoma peritonei. Considerable controversy exists on their pathologic classification and nomenclature. Clear understanding of the histopathologic diversity of these neoplasms helps in establishing proper communication between the radiologist, the pathologist and the surgeon. In this article, we present a brief discussion of the current taxonomy and nomenclature of mucinous neoplasms of the appendix followed by a review of their imaging features. Important points including the significance of identifying extra-appendiceal mucin at imaging, the new classification of pseudomyxoma peritonei into low- and high-grade varieties and the significance of simultaneous ovarian and appendiceal neoplasms are highlighted.

Young and elderly patients with type 2 diabetes have optimal B cell responses to the seasonal influenza vaccine.

We evaluated immune response to the seasonal influenza vaccine in young and elderly patients with type 2 diabetes (T2D). Immune measures included the in vivo serum response to the vaccine by hemagglutination inhibition (HAI) and ELISA in 22 patients (14 young, 8 elderly) and 65 healthy age-matched controls (37 young, 28 elderly). B cell-specific biomarkers of optimal vaccine response were measured ex vivo by switched memory B cells and plasmablasts and in vitro by activation-induced cytidine deaminase (AID) in stimulated cells. Markers of systemic and B cell-intrinsic inflammation were also measured. Results show that in vivo responses, as well as B cell-specific markers identified above, decrease by age in healthy individuals but not in T2D patients. This occurred despite high levels of B cell-intrinsic inflammation (TNF-α) in T2D patients, which was surprising as we had previously demonstrated this negatively impacts B cell function. These results altogether suggest that valid protection against influenza can be achieved in T2D patients and proposed mechanisms are discussed.